A nurse is reinforcing teaching with new parents about the provider's prescription for a serum bilirubin test. Which of the following statements should the nurse include in the explanation?
"Your baby is at a higher risk because they were born with congenital dermal melanocytosis.”
"This is because your baby is breastfed. You should start supplementing with formula."
"Your baby is at a higher risk because they have had four bowel movements in the first day of life.”
"This is because your baby's liver is not yet efficient at breaking down red blood cells."
The Correct Answer is D
A. "Your baby is at a higher risk because they were born with congenital dermal melanocytosis.": Congenital dermal melanocytosis, also known as Mongolian spots, are harmless pigmented birthmarks and are unrelated to bilirubin levels or jaundice risk in newborns.
B. "This is because your baby is breastfed. You should start supplementing with formula.": Breastfeeding itself is not a reason to stop or supplement with formula unless medically necessary. Breastfeeding jaundice can occur, but proper feeding techniques and frequency usually manage it without needing supplementation.
C. "Your baby is at a higher risk because they have had four bowel movements in the first day of life.": Frequent bowel movements actually help lower bilirubin levels by aiding in the excretion of bilirubin through stool, so this would not increase jaundice risk.
D. "This is because your baby's liver is not yet efficient at breaking down red blood cells.": Newborns often experience physiological jaundice because their immature livers cannot efficiently process the breakdown products of red blood cells, leading to elevated bilirubin levels in the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client who has hearing loss with a friend interpreting: A friend interpreting does not meet the legal standards for ensuring accurate communication during informed consent. A licensed medical interpreter should be used to avoid misunderstandings and to ensure that the client fully understands the risks, benefits, and alternatives of the procedure before consenting.
B. A client who has not spoken with the provider yet: Informed consent requires that the provider explain the procedure, risks, benefits, and alternatives directly to the client. Without this discussion, the client lacks the necessary information to make an educated decision and cannot legally or ethically provide informed consent.
C. A 15-year-old client whose caregiver is not at the bedside: Minors generally cannot give legal informed consent without a parent or legal guardian present, unless specific exceptions apply (such as for emancipated minors). A 15-year-old without their caregiver present does not meet the criteria for giving valid informed consent for surgical procedures.
D. A married 16-year-old client accompanied by their spouse: A married minor is considered emancipated in most jurisdictions and can legally make healthcare decisions, including providing informed consent. Their marital status grants them the legal autonomy needed to consent to medical treatments without requiring parental involvement.
Correct Answer is D
Explanation
A. Difficulty swallowing: Difficulty swallowing, or dysphagia, is not typically a direct indicator of unrelieved pain. It could suggest neurological or throat-related issues rather than being a primary symptom associated with inadequate pain control.
B. Constipation: Constipation is a common postoperative complication, often related to anesthesia, immobility, or opioid use. While it is important to address, it does not directly reflect the client's current pain level or effectiveness of pain management.
C. Urinary retention: Urinary retention can occur due to anesthesia effects, pelvic surgery, or opioid administration. Although it is a significant postoperative concern, it is not a reliable or direct indicator of unrelieved pain.
D. Restlessness: Restlessness is a common sign of unrelieved pain, particularly in postoperative clients. When clients are uncomfortable or in significant pain, they may appear restless, anxious, or unable to remain still, signaling the need for further pain assessment and intervention.
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